Changes in medical errors after implementation of a handoff program

Amy J. Starmer, Nancy D. Spector, Rajendu Srivastava, Daniel C. West, Glenn Rosenbluth, April D. Allen, Elizabeth L. Noble, Lisa L. Tse, Anuj K. Dalal, Carol A. Keohane, Stuart R. Lipsitz, Jeffrey M. Rothschild, Matthew F. Wien, Catherine S. Yoon, Katherine R. Zigmont, Karen M. Wilson, Jennifer K. O'Toole, Lauren G. Solan, Megan Aylor, Zia BismillaMaitreya Coffey, Sanjay Mahant, Rebecca L. Blankenburg, Lauren A. Destino, Jennifer L. Everhart, Shilpa J. Patel, James F. Bale, Jaime B. Spackman, Adam T. Stevenson, Sharon Calaman, F. Sessions Cole, Dorene F. Balmer, Jennifer H. Hepps, Joseph O. Lopreiato, Clifton E. Yu, Theodore C. Sectish, Christopher P. Landrigan

Research output: Contribution to journalArticlepeer-review

527 Scopus citations


BACKGROUND: Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. METHODS: We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. RESULTS: In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P = 0.79). Sitelevel analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P = 0.55) or in resident workflow, including patient-family contact and computer time. CONCLUSIONS: Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow.

Original languageEnglish (US)
Pages (from-to)1803-1812
Number of pages10
JournalNew England Journal of Medicine
Issue number19
StatePublished - Nov 6 2014

ASJC Scopus subject areas

  • Medicine(all)


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